Chronic pain for the rest ofus

Today, June 11, 2015 the Supreme Court of Canada which is the highest court in the land, ruled that cannabis when legally prescribed by a Canadian physician can be administered by whatever route and by whatever formulation is appropriate in the circumstances.

This, on the surface, seems rather silly since many Canadian patients make brownies and cookies to ingest their medicine and of course many more use the same to get high.

That old law requiring inhalation rendered the brownie consumer a criminal! Most legitimate medical cannabis consumers use a vaporiser as far safer option but there will always be hard core cigarette smokers who insist on inhaling burning plants and carbon monoxide despite the obvious.

The Supreme Court saw what was obvious and rejected by the Harper government could not or simply would not see. The current government did everything in it’s power to limit the opportunities to exploit the medicinal potential in cannabis.

The conservative rant( largely aped by the Canadian Medical Association) was “no evidence” when evidence from around the world and in peer-reviewed journals, and respected ones, is really quite abundant. Now much of the evidence is offshore. Why is this the case?

First the Canadian Medical Association and the Harper Government are fundamentally against cannabis in any form for any use. The upshot is that the evidence is so prevalent and the pressure so great these conservative philosophers have been require to grudgingly give some ground.

A far more progressive group, the College of Family Physicians of Canada, initially refused to accredit even teaching programs about medicinal cannabis in the dried form. They have since changed their position and produced a good document of Preliminary Guidance for medicinal cannabis prescribers to use as a guideline. Now clearly that document is far too conservative for radical marihuana fanatics who, like the prohibitionists, are unwilling to let facts get in way of a strong opinion.

In the final analysis for those with an open mind and a clear conscience only legalisation to legalise cannabis will permit high quality research and fair marketing.

Why do I say such a thing? Marihuana is illegal in Canada and the United States, In America cannabis is classified with heroin and LSD as high-risk with no possible medicinal value. Just try for a moment to imagine how incredibly difficult it would be to get institutional approval and government sanction for research! Then from the other corner of their bureaucratic mouths come the Holy words-“THERE IS NO EVIDENCE”! It is like killing your parents and suing for an orphan’s pension!

Let me describe a case in point. One of the best studies, published in the Canadian Medical Association Journal,from a group in Montreal headed by Dr. Mark Ware show efficacy of 9.4% inhaled(vaporiser) in treating a very severe form of nerve pain in subjects naïve to marihuana(never used marihuana before). There was also significant improvement is sleep quality(the primary endpoint in the study was pain, however). There is an interesting sidebar to this study which illustrates the need for legalisation in some form. The three cannabis concentrations had THC levels of 2.5, 6.0 and 9.4% delta-9 THC and were available from the then only legal cannabis producer in Canada, the Harper government, which was good. However, the placebo(a cannabis strain with zero percent THC, yet still legally classed as a level one drug and highly illegal technically was grown in the United States. It took Dr. Ware and his team several years to bypass the legal hurdles preventing the import of this illegal cannabis with no THC. This should convince you why legalisation is important if not, necessary.

Cannbabis research will not be possible in Canada on an even par with other medicinal products unless there is some form of legalisation. No university or public agency will easily support research on an illegal substance where their participation may be used against them.

To hear the common speak today stress is public enemy number one and everything from cancer to the lack of world peace and prosperity is blamed on stress. It would appear that stress is a terrible malady and must be eradicated at all cost.

Stress did not enter the lexicon until fairly recently. The actual word is attributed to ‘Hans’ Selye an Hungarian-born endocrinologist who died in 1982 after a distinguished academic career in Montreal. Based on the earlier work of Bernard(milieu interior-referring to the peculiar stable composition of the fluids within tissues and cells) and Cannon (homeostasis-the mechanisms that maintain the stability of these internal fluids). Selye studied the processes and effects of the body’s efforts to resist and cope with events that try to disrupt or change the organism. He called the pressures ‘stress’ and the process of resistance by the animal the ‘General Adaptation Syndrome’. It was, as described by Selye first an ALARM phase followed by RESISTANCE, then finally an EXHAUSTION stage where the organism ultimately succumbs.

The duration and robustness of the three phases in response to a given stressor depends on our genetics and reserve(essentially our total health.

Stressors are anything which would attempt to cause us to change from the status quo. Selye felt that each event required a consumption of our vital energy and was the basis of much of aging and disease.

The recent condemnation of the medical literature by the Editor-in-Chief of the prestigious Lancet medical journal was stated earlier by the Editor of The New England Journal of Medicine.

In 1968 when I started medical school Dean Murray held up a copy of Harrison’s internal medicine textbook saying, “Half of what is in this book is likely wrong and we do not know which half. I challenge you all to seek the truth.”

In my own practise I rely much more heavily on my own personal scientific knowledge base and the wisdom of respected colleagues than on the ‘so-called’ peer reviewed medical literature combine with the reports of my patients about the effects of treatment.

The medical literature industry is contaminated by the principle of tenure, publish or perish, and the need to create economic and industrial empires. Clearly, there are committed, ethical individuals within this structure and they are to be commended as they strive to work in the pollution.

Evidence based is the mantra spoken by those who give thumbs up or down to new treatments or technologies and even ideas. Sadly, it is clear that either way half of this evidence is erroneous or even falsified. That should lead us to the obvious conclusion that the future of medicine is being decided by political and economic whim and not the scientific method combined with patient care.

Let us not forget that even decisions about physician punishment by our licencing bodies is often based on the evidence gleaned from the pool of clearly suspect and tainted scientific medical publications from prestigious medical journals.

In one simple example, the Canadian Pain Society, and rightly so, in it’s guideline for the treatment of neuropathic pain includes medications which are used off-label( not actually recommended in the product monograph for that indication). At the same time paying agencies are increasingly attempting to discourage paying for anything except on-label prescribing. If this were successful, it would greatly reduce the cost of public medicare and insurance payouts for drugs because a large proportion of drugs used in many areas are off-label and we would have no drugs at all for many diseases.

So why do we use so many drugs for which there is no evidence? In order to actually print on the product monograph that a drug is indicated for a disease or symptom governments require expensive and specific study. The only real reason for drug manufactures to do that was if they could have a reasonable expectation of profit. Of course this is scorned by academics and neo-liberals, but in the real world it is no different than asking you to go to work with no reasonable expectation of a paycheck. Sadly, this metaphor is rarely used by the fanatics, usually well-paid, who attack pharmaceutical companies.

It is time to return science to real scientists in medicine who, based on their knowledge and experience conceive of new therapies and after due diligence about risks, introduce these ideas to patient care. Current roadblocks based on the prejudice of academia and economics are stunting growth of medical science. It is time for a scientific revolution.

Cannabis has been with mankind for twelve thousand years and used in many ways from fiber(not the dietary kind) ,medicine, soporific and most recently, whipping boy.

Despite multiple peer-reviewed papers documenting the potential use of cannabis in medicine most of main stream medicine remains opposed or ill-informed and about cannabis and seem content to remain so.

How is it scientifically educated individuals have become so reluctant to take a look at the scientific evidence when it comes to cannabis?

Well here is my take on the issue. Today is Adolph Hitler’s birthday as well as my devoted and long-suffering bride. However, and far more significantly, today is 4-20, National Pot Day in case you were on Mars and missed it! There are lots of tales about the origin of 4-20, including it being a police radio code for ‘marihuana smoking in progress. The one I prefer is that it was the time 4:20PM when a certain group of arts students got together to have a joint after classes were over for the day.

However the day got it’s moniker, it has become quite a big deal amongst the recreational pot users who are inclined towards public disobedience.

Marc Emery, the newly freed Prince of Pot was given airtime on CTV today from Vancouver where Pot Day is almost a provincial holiday. He indicated he was planning to pass out several hundred joints to the disobedient who will be out in large numbers to smoke pot, wave signs and just make a nuisance of themselves for the not so disobedient who just want to go about their business.

Now the term civil disobedience when it comes to Pot Day in Vancouver is about a disobedient as goose hunting in Kindersley, Saskatchewan since cannabis smoking is almost a legal requirement to live in British Columbia.

Let me get to the point. Recreational cannabis is ILLEGAL in Canada. Whether BC cares or not is irrelevant. That is my real problem.

In our practise of chronic pain cannabis is used legally, yet illegal everywhere else, to alleviate chronic pain in patients who have failed other care or who choose not to take opioids for pain and other modalities have failed.

What has been our experience? It is not generally more effective then standard therapies yet carries somewhat less overall risk. It is used most commonly for conditions with painful arthropathy (the other joints) and neuropathy(pain related to damaged nerves). Opioid use is lower in cannabis patients. The majority of them are gainfully employed. We used mandatory urine drug testing in all our pain patients and we do not see more illicit drug use in the cannabis patients. You could not pick them out as a group on the street. Many of these patients are referred to out clinic by doctors who are unwilling to prescribe cannabis. Please remember this is the experience of our clinic and not any kind of peer reviewed research on our patients.

So the why is 4-20 the curse on medical cannabis?

In my estimation the reason for the lack of support for medicinal use of cannabis is simply because it is illegal. Once legalised, cannabis will have it’s fair chance to prove it’s value without being seen as an evil illegal gateway drug used by young rebels and aging hippies who never grew up. Most College regulatory bodies for doctors have little or no support for cannabis. How can anyone blame these bodies when the stuff is illegal? In the case of America cannabis is considered right up there with heroin as a scourge.

So I see 4-20, Pot Day, the celebration of illegal recreational use as a curse on my practise. In Canada the Harper Government has forced doctors into being the gatekeepers for medical cannabis while hypocritically refusing to do the right thing and make it legal.

Chronic pain is almost always caused by non-fatal conditions that are stable. Most chronic pain patients are not dying from their disease. In chronic pain the pain is the disease and not the back, the shoulder, the neck or wherever the pain is felt. If not for the pain, most chronic non-cancer pain patients are capable of normal activity including work of a physically demanding nature.

Sadly, because of lack of education in pain, there are many pain patients who have been told not to lift, not to bend, not to exercise and they assume it is because they will harm themselves. In fact, most chronic pain patients will gain benefit, not harm, from normal physical activity.

Where did all this fear come from? Mostly, it is from the inferences drawn from acute pain where the experience(pain) can be close to the actual health of the tissue and is actually protective and the pain will go away when the tissue heals.

If the back pain we experience is no longer an indication of back health and we continue to protect the back we will eventually become crippled by the pain and unable to function normally despite the back being quite stable.

Recently, I heard a speaker from Toronto(a pain doctor) emphatically state that if we validate the pain(to me that means to agree that the patient has pain) we are legitimising their disability. This is one of the great debates in pain medicine. If the patient has no actual physical disability and the pain is the problem, why not just pretend it is not there-just do not validate the pain?

Can we make the pain better just by telling the patient it is not real? Pain is an experience that resides in the conscious brain. Is the patient disabled because she believes the pain means she is crippled or likely to become so if she works?

Are we making patients worse by agreeing they have pain? How could we even study this issue and would it be ethical? Patient satisfaction is increasingly being used as an index of quality of care. Is there an educational tool that allows us to understand that although their pain is real and severe that it doesn’t mean their back(neck,head,shoulder) is ruined and they will soon be a cripple if they use it normally? Patient who are engaged in their treatment are more likely to improve. Can this engagement be increased with high quality pain teaching? The brain is not a computer and it has no compartments. Can education about the meaning of pain actually reduce fear of movement and actually reduce pain and disability.

Pain is intended to protect us from, during and after injury. In chronic pain this is not so. In chronic pain the pain actually makes us worse in so many ways. Are there techniques we can use to restructure our brain so it can recognise the difference and improve chronic pain? We can train the brain to recognise different wine varietals, can we not train the brain to be less attentive to pain that is not helping?

If we are convinced(and I am) that the pain is real in chronic non-cancer pain and yet is not an indication of real tissue threat, does that mean it is a mistake to validate the pain?

Are there patients who are so mentally disordered or so devious that we can never make them accept the concept that they have real pain without real tissue damage and they can return to normal work and function? Of course, but the numbers are very small. If research could tell us that education can reduce pain disability reliably and significantly in chronic non-cancer would we be less reluctant to acknowledge(validation) that patients are truly having pain?

We need much more research in this area. Could education and brain rewiring techniques work as well as surgery, drugs and injections in some patients? There are some studies that indicate that increasing patient satisfaction may worsen, not improve outcome in some patients. Is this because a less educated patient may not engage in optimal care? Is patient directed care a bad idea or is it a poorly educated patient directing care that is a bad idea?

Try to answer these questions and I feel we will have better pain care that is better accepted by patients without imperious and insensitive caregiver or resorting to the path of least resistance.

Most of us have multiple personalities when this topic comes up. If we are talking about bending spoons , moving coins or killing goats in the movies(The Men Who Stare at Goats) most of us are pretty skeptical.

However, when we see someone suffering from chronic pain with no obvious pathology(trauma, tumour, infection, deformity or the like) we are often tempted to think, “Why don’t they just get over it and stop making such a fuss”. Many pain patients report feeling judged in this manner often and being very resentful.

Of course, some of this relates to a widely held misconception that chronic pain is imaginary and pain is only real if you can identify a site where the body is being injured or at least very close to being injured. It is also generally understood that humans can imagine many ,so the concept of imaginary reality is quite established in most of us. We can imagine cats and dogs and palm trees and being on holidays. We are also aware that we can stop this imaginary reality anytime and move on with our tasks.

So, if chronic pain is imaginary, why can’t we just imagine it to go away or are chronic pain patients somehow built in such a way that they can only extinguish pleasant memories? That seems a bit of a stretch for me.

If we could extinguish pain by some kind of active mental exercise that would be excellent if it were easily learned and especially helpful in chronic pain where the body is not in imminent danger or injured.

Studies of CBT(cognitive behavioural therapy-one of these mental exercises) have shown only a small effect(but better than none, of course) on pain and suffering.

Can thought actually move matter(if so then maybe changing a mere experience like pain might be possible, even if difficult)? Of course. When you think(mind) about standing up you can actually convert mind into matter-the act of moving yourself to standing up. Silly as it sound we convert mind into matter millions of times and never realise how magical it really is!

Why can’t we do this with pain? Evolution has made it very difficult because pain, like suffocation is a highly evolved system to protect our DNA from harm so it can be passed on successfully to the next generation and further the survival of our species(well more precisely our species specific DNA). Allowing us to easily choose to stop the pain would be bad for the species as it would make us much more prone to risk ourselves(our DNA).

Acute pain can totally immobilise an animal and prevent it from being able to escape when injured. That is bad for the species specific DNA as far as survival is concerned.

Last June, while participating with my staff in an extreme obstacle race, I fell from a log(don’t say it, I know it ‘s easy) and rotated, landing on my right shoulder and the right side of my head on the caliche in the ravine. The immediate pain was intense and forced me to lay perfectly still to the chagrin of my team who were mortified. Within a few seconds, the pain was gone and by the time the team and the paramedic got into the ravine I said I was fine, just a bit shaken and a lot embarrassed!

Just as if the sabre-toothed cat was still chasing me I became able to move and over the next 45 minutes finished the ‘race’ picked up my attendance prize(I am not an athlete!) and got in the back seat ( my wife who had seen my fall was unconvinced at my protestation of wellness). We stopped in Taber(about an hour later) for lunch and by then I needed help to get out of the car being unable to move my right arm. Lunch was good since I am in my right mind(left-handed). By the time we got to Medicine Hat anything but minor upper body movement was painful beyond description. My chiropractor BFF came over and diagnosed a separated AC joint and possible shoulder damage. In fairness to him he really couldn’t examine me because of the pain at virtually any movement and I could only take shallow breaths. He sent me for x-rays the next day. The initial xray requisition was for the shoulder revealing the AC joint damage but it wasn’t until my chiro asked the rads to have a closer look that they spotted the displaced fracture of the second rib! It is difficult to imagine the amount of energy it takes to break a rib as well hidden(and in my case as well padded) as the second rib. For the next three weeks I slept in a recliner because it was impossible to sit from lying down. I developed a fracture blister over my back and a year later the scar of the fracture blister is all that remains. In all my years of practise I have never seen a second rib fracture.

For years I have taught students and patients about the brain’s ability to suppress acute pain in an emergency and now that I have experienced it I am witness to one of nature’s most powerful miracles. More importantly the brain did this without me actually doing anything-I really wasn’t aware I was injured!

It is now clear to me in more than just an academic sense that pain can be totally independent of the health of the body.

What an amazing thing if we could we could re-activate that internal pain control system in chronic pain. Sadly, that has not been possible yet.

What if it were possible to reroute brain circuits to reduce the experience of pain even if we are unable to repair the damaged nerves which are responsible for the sending the signals.? Recently, a psychiatrist colleague, Dr. Stein, who is an expert in treating chronic non cancer widespread pain, like fibromyalgia, introduce me to the to the clinical and research work of Dr. Michael Moskowitz. He is involved in an evolving paradigm whereby the brain can be encouraged to create new pathways that allow us to experience less or even no pain in situations where the chronic pain had overwhelmed the patient’s consciousness. Shortly thereafter, I read a book by Dr. Norman Doidge called The Brain that Changes Itself wherein Dr. Moskowitz’ work figures prominently. I recommend it to furhte understand the paradigm shifting concepts in brain-body medicine.

The title certainly does not apply to me personally and the second should apply to all pain doctors and should also apply to everything we do.

This article has started enigmatically for a good reason. The rather concise title of this document and the first line actually were produced by the same pain doctor. Of course you are right they are mutually exclusive. The two statements represent a metaphorical ‘Heisenberg Uncertainty Principle’.

It has become politically and medically unpopular to advocate the use of opioids in chronic non cancer pain. This concept of virulent opiophobia will be most likely expressed in a group of doctors gathered together to discuss the conquering of pain via surgery, invasive nerve injections or destruction, behavior modification and addiction.

In this particular case it was a doctor’s group dedicated to the treatment of pain by injection and burning of the offending nerves. In his address to the audience, the title statement was made during his opening remarks and was met with a lot of seemingly grateful smiles and nods. Clearly he struck a resonant chord suggesting there were a considerable number present who took his remarks at face value-the total prohibition of opioids in chronic non cancer pain.

This mantra is spreading its dark countenance over North America following the upsurge of ‘hillbilly heroin’ as Oxycontin became widely known. Fifty years ago opioids(painkillers derived from opium poppies and synthetic chemical which work the same way) were rarely used for chronic pain. By the 1980’s it became clear that patients dying of cancer could be relieved of much of their pain with morphine and similar drugs. A public outcry and the consensus opinion of hundreds of nurses, doctors and clergy around the world treating the dying convinced the World Health Organisation to release the WHO Ladder for the use of opioids in cancer pain in 1986.

For palliative care patients the result has been almost miraculous. What happened next was horrendous yet largely well-meaning. These same opioids began to be widely recommended for the millions suffering chronic noncancer pain, based on their success in palliative care and research showing their safety and low addiction risk in acute pain and operating rooms. It was also true that some drug companies exploited this opportunity to market opioids to doctors treating noncancer and nonacute pain.

Opioid use, misuse and harm has skyrocketed and now the ‘genie’ has to be put back in the bottle. The same press that pushed for wider availability of opioids has now tossed doctors and pharmaceuticals under the bus and the only press for opioids is doom and gloom. Addiction and opioid related deaths have supposedly reached ‘epidemic’ proportions of a biblical scale.

The rise of a politically popular lobby of opioid prohibitionists has made rational discussion of opioids almost an impossibility. Such phrases as ” I do not prescribe opioids” have almost become campaign slogans like, “I will give up my gun when they pry it out of my cold dead fingers” for the fanatical right. As was said in the movie ‘Paul’, “You just can’t talk to those people”.

When speaking to a group of interventional pain docs with little interest or experience with opioids making such a dogmatic statement is likely to be well received-and it was.

Sadly, there are many North Americans living productive lives with chronic pain on stable effective doses of opioids. You do not hear about them and you will not. There is neither the political will or the funding to gather the evidence. Chronic pain patients are a silent lot and there are no huge organisations like the American Cancer Society to fly the pain patient flag.

Should we be bludgeoned back to the dark ages of opioid prohibition we will have lost a valuable tool that has and can benefit many chronic pain sufferers. In chronic non cancer pain opioids have been shown to be at least as effective in selective patients as less maligned drugs(gabapentin, pregabalin, duloxetine).

The less maligned drugs are generally not used to get high and rarely addictive. This gives them the benefit of not being seen as ‘forbidden fruit’.

Now back to the first line of the piece.

I do not prescribe opioids excluding special circumstances. In patients with chronic pain the statement can and should apply to all medical(drugs) surgical and injection-based treatments. Most patients requires none of these.

That said let me come to my point. We need to be intellectually honest. You see, the title of the piece was made to a select group of doctors and the first line is on the same doctor’s homepage at the university where he works and is soliciting new patients.

It all seems so much like the recent election in Israel where on the eve of election facing defeat Netanyahu repudiated a two state solution, courting the right only to step directly backwards the next day with defeat off the table. Many Canadians will remember the same feat of intellectual duality that Pierre Elliot Trudeau used to end Joe Clark’s Prime Ministerial hopes.

One either prescribes opioids or not. Every patient and treatment should be individualized not ‘dogmatised’.